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HomeMy Public PortalAbout4937 GOLDEN WEST AVE_Sewer__ r CEAAPPLICATION FOR PERMIT 64 CIE806 DD COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGnIM BUILDING AND SAFETY DIVISION BUILDING � vv�Offit 1 E_NMM Co>m A. a b IES. �7 af twuunq LOCALITY HKAR[RT A_ Ute'/[ FOR APPLICANT TO IN' °"°" " /T /rT DESCRIPTION LOY H OWNER sir Q 5--3 MAIL BLOCK TRACT `57 AbDRW O ��JJ����� NO. OF BLDOB. SIZE OF LOT Z-00 HOW ON LOT CITY L. NO. USEOF DISTRICT MAPAc, OUPMAP PROCL/ pY Of SK J'�CONTRACTOR )L41 I ' ADDRESS - CONNE ON DATA CITY TIL. NO. STATION O DEPTH STATE MANHOLE REFERENCE UPPiR REGISTRATION NO, COUNTY LOWER NO. DESCRIPTION OR WORK FEE TYPE OF CONNECTION LENGTH FROM HOUG6 SEW"CONNECTING TO Y. CURD 1P.L_ Y.L.TO P.L. PUBLIC SIW[R 0 65.00 P.C.NO. ■ PTIC TANK,f P O[FI OR O■NO. PITS AHD/OR DRAINFIELD 0 510.00 CO.IMP.NO. ^ HODS[6[WERCQNHICTING TO TRUNK PERMIT NO. PtRY TT HO. �}J� 'PRIVATE DISPOSAL SYSTEM 0 63.00 CONN[ ADDITIOHALf D . �r AFFIDAVIT IAmm wg1Dl7 RECORD.I GTR.NO. DATE //�►► WORK TO HOU.[SEW[R 0 63.00 J A OVERFLOW SEEPAGE FIT,DRAIHFI[LD Oy4rJ/ IxTN.,cu.FooL oRYw[t4 YANHoLt 6e.00 R AIR A DO HWM.OR IT,WIDENING SEWER OR DISPOSAL BY.TIM 3.00 STATI ENCROACHMENT i PERMIT NO. INDUSTRIAL WAST[APPROVAL CHA RO[S OWNERrS PE mff s z o0 AMORMATION TOTAL FEF o-0 CONNECTION CHARGE FI[ 'I RAVE AT THIS DATE A CONTRACT WITH WHI HERtIN NAMED CON- REIMBURSEMENT FI[ TRACTOR TO CONNECT 'EHE ABOVE D[fCRI■EI} ITTINO DWELLING TO TH[ PUBLIC SEWER. AWROVAIS DATE IHSrEQTQ R'S■IO HATU R[ 51GffNED TH18 T_DAY OF iO_ OWNER OR NEW HOUSE.EWKR OWNBRD AGENT CONNECT ADDITIONAL ■U ILDINO OR WORK ADDRI/S 691-TIC TANK,SEEP,RITC) I HEREBY ACKNOWLKDQE THAT 1 HAVE READ THIS APPLICATION AHD/OR DRAINFI[LD AND STATE THAT THE ABOVE 16 CORRECT AND AOR[[ TO COMPLY WITH ALL COUNTY 0RDI NA NCIS AND STAT[ LAWS REGULATING PLUMS I Na AND BEW IRS. CESSPOOL ❑ DRYWILL ❑ I HBRI■Y CERTIFY THAT 1 AM PROPERLY REOISTERED AND/OR ALTIM REPAIR,SEWER OR LICENSED AS REQUIRED BY LO. ANGLES COUNTY ANQ STAT[ OF S[WAO[DISPOSAL SYSTXM CALIFORNIA OR THAT I AY THE LEGAL OWN R , AND INTEND TO DISCONNECT PLUG AND RESIDE IN, TH[ A EIFcRISEO R[SID[ I PROPERTY. ABANDON MOUS[BEWIR ■IONAT.UR[ BACKFILL SEF'LC TANKS ❑ OF PERYfTTII 6[v,r17fU ..,OL. VALIDATION ROBERT A. WOOD cec M.0. CATH SUPERVISING MECHAIQICAL ENdINEER 566 3 5 5�8 MC14 1 0 D 5.0 Q- q